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Friday, January 29, 2010

What a nursing assistant will tell us...if we ask

A friend recently forwarded me an update to a story first reported in the Washington Post in May 2009 about a home care nursing assistant, Marilyn Daniel. (Here’s the update). Using quotes and photographs, the author describes a typical day of visits—from transportation challenges to detailed, moving stories of a few of her patients. It caused me to pause and reflect upon the caregivers closest to our geriatric patients. Nursing assistants provide the greatest amount of direct care to our patients whether in hospitals, nursing homes, or homes. For me, this article aptly notes the challenges of the job, the importance of continuity of care, and the difficulty for home health aides when given a next “case” right after a long standing relationship with a patient ends (or perhaps when hospice comes in and negotiations can’t be reached for keeping the same home health aide). The audience here at GeriPal is one that knows these issues well, but when a photographer/writer captures it so movingly, I can’t help but call attention to it.

It is projected that there will be a 50% growth in home health aide positions in the next ten years because of the expansion of home care for our geriatric population (US Bureau of Labor Statistics). How will we work with home health aides to increase retention? How can we argue for better compensation for such a demanding (physically and emotionally) position? And for those of us involved in geriatric palliative care, how can we ensure that palliative care education is offered and encouraged for home health aides?

In the larger picture, offering continuing education and acknowledging specialized training is a start. I know that programs such as ELNEC-Geriatric include specific content and attention to nursing assistants (self disclosure - I’m part of the team offering this course in Philadelphia in March-link above is for this, but see * below for more details). And in recognition of additional education and experience in palliative care, HPNA (through NBCHPN) offers certification for nursing assistants. These are a start—as was the public attention given to the role in the Washington Post articles. In my own practice, the same as with most of you I assume, I often elicit opinions and thoughts from the home health aides caring for an individual. But in the smaller, every day picture is this enough? How we can better include nursing assistants in palliative care teams? I don’t have the answer, but I do think that as we continue to consider how geriatric palliative care is delivered, we all need to advocate for nursing assistants as valued members of the interdisciplinary team.

9 comments:

Most of my experience with nursing assistants comes from hospital work. In the hospital where I used to work we asked several nursing assistants on the palliative care unit how it felt to work with physicians in end-of-life settings. They told stories of remarkable rudeness, often relating that they felt like "pieces of furniture." Rarely were they asked their name. Despite spending more face time with patients than anyone else, they were rarely asked to share what they saw. And all too often they were not included in the care team's debriefing of suffering and loss.

As for your larger point/question - the people who're closest to the daily realities are most often the ones who're overlooked. It's like there's some kind of unwritten law based on an inverse ratio, where those who have the least contact exert the most control.

I really appreciated Susan's post bringing attention to the the role of nursing assistants in palliative care and the challenges they face. They provide invaluable care to so many. Thanks again for geripal! Kathe

Thanks for this very important post. In my experience, there is no discipline that knows more about the overall health status, including psycho-social issues, than the nurse aide. Yet they are the ones least likely to be able to get time off for support, training, or interdisciplinary meetings. ELNEC-Geri offers great tools for teaching nurse aides about hospice and palliative issues, but it still behooves all of us to assertively insist that NAs be a primary part of the team. In my work setting, the only way a NA is guaranteed to be consistently assigned to our hospice unit (as opposed to rotated throughout the nursing home) is if they are nationally certified. While HPNA offers NA certification, many highly skilled nurse aides are not experienced test takers and,in my setting, my not be comfortable reading and writing in English. The notion of a taking a traditional test is out of reach for many NAs. I wish HPNA would consider other options for certification for this valuable group of health care providers. Perhaps a combination of standardized trainings with experience could be another option. What do others think?

My magic wand would start with training and education programs developed and run by the individual facilities, and tailored to the learning needs and styles of their own NA's.

The programs would be based on ELNEC content and concepts, and would at least provide the NA's in that facility, and perhaps others in the same or adjacent communities, with important skills and knowledge in lieu of a broader certification.

Yes – there are many challenges for recognition and support of nursing assistants and the vital work they do. The ELNEC Geriatric curriculum and its sections for nursing assistants are an excellent resource, but education isn’t the only factor. Many barriers are not always obvious, like what Patrice points out. There are studies that support consistent assignments, but there is more to consider. I have been thinking of the saying "it takes a village to raise a child"; in other words it takes a community where everyone is involved and prepared, so it also “takes a village” to provide high quality & compassionate end-of-life care. I’m not sure I’m expressing this very well. I do wonder what others are doing or have seen that supports nursing assistants. Kathe

I often see Nursing Assistants (and other "non-professional" staff) treated like "furniture"...These folks are often with the patients more then anyone and can make all the difference by there actions and comments!I tell nurses when I teach: Would you treat a patient like they were a "nobody" because they were "just an aide"?

I teach the ELNEC programs and welcome Nursing Assistants to attend and become PCRPs (Palliative Care Resource Professionals--nurses become PCRN's--Palliative Care Resource Nurses) but only have gotten a few to come...and then they are not given the respect they deserve afterward from their managers...Geriatric ELNEC is the only one I haven't taught and now I'm excited to do that with the additional content directed toward the CNA.

Unfortunately, this seems to be an area of predjudice in medicine. Nurses especially (but also MDs!) need to listen to what these folks have to say. But then, I think we all should be listening to our patient's lay cargivers and that often does not happen either...

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